Abstinence refers to complete avoidance of all mood-altering substances in Recovery.
Harm Reduction, on the other hand, has often come to mean: the substitution or “replacement” of a toxic addictive substance with a less dangerous but analogous prescribed medication.
Recently, my tech support/researcher Meagan Park showed me a thought-provoking article from the Windsor Star written by Michelle Ruby and Trevor Wilhelm: “The Solution: Abstinence gives way to a more medical approach” dated 3/7/2019.
Traditionally, complete abstinence has been the goal in treatment centres and community Recovery meetings. Some of the medications used for the treatment of alcoholism include Acamprosate to diminish neurological damage caused by alcohol withdrawal, Antabuse to cause an adverse reaction to alcohol consumption, and Naltrexone to diminish alcohol’s pleasurable effects. They are not really Harm Reduction modalities, using the above definition of Harm Reduction – rather they are used to facilitate and promote abstinence from alcohol. In prescribing some of these medications, health care professionals now have the opportunity to counsel alcohol-dependent patients and set up regular follow-up appointments to monitor the patients’ progress.
On the other hand, Methadone and Buprenorphine (Subutex) are genuine “Harm Reduction” medications that are used to “replace” the more dangerous, unstable and unpredictable street and pharmaceutical opiates with a more stable, controlled and smoother pharmacological action. These “replacement” opioids can either be used to detoxify an opiate addict over 1 to 6 months or they can be employed as long-term open-ended opioid maintenance therapy to stabilize the lives of opiate-dependent patients.
These Harm Reduction strategies have elicited a lot of controversy. Some treatment centres and community Recovery meetings have discouraged Harm Reduction as a legitimate treatment because, in their view, the recovering addict is not really “clean” or free of all mood-altering substances. Yet the statistical evidence is overwhelmingly in favour of Methadone and Buprenorphine treatment in terms of reduced mortality through decreased rates of overdose, reduced morbidity, prevention of Hepatitis B and C, and HIV infection (through the prevention of sharing used needles). The beneficial effects are so clear that the scientific and medical research community has given the evidence a Grade A rating: evidence so compelling that further funding for research regarding this issue is no longer deemed necessary and is even discouraged!
The discrimination against Harm Reduction patients should be a thing of the past. Discrimination has no place anywhere, neither in treatment centres nor in Recovery meetings. Rather, we should be focusing our attention on how to make Methadone/Buprenorphine treatment available to the tens of thousands of patients suffering and dying in the current opiate crisis.
As in the treatment of alcohol dependence, the opportunities for health care professionals interacting meaningfully with patients afflicted with opiate dependence can be greatly enhanced by the simultaneous provision of pharmacological interventions. These treatments always require regular appointments, follow-up and counselling. Regular medical appointments allow for the testing and assessment of concurrent medical conditions such as TB, Hepatitis B and C, and HIV, to name just a few health issues common in patients with addiction. Psychosocial issues can also be addressed in this setting.
Even the Harm Reduction advocates do not deny that abstinence is preferable or indeed the ultimate goal. Yet in many cases, the abstinence model is simply not feasible, especially in early Recovery, and in the under-privileged populations with limited social structures and supports. The sooner everyone realizes and accepts this, the more efficient and focused the allocation of medical services and resources can be; this is especially necessary in combating today’s disastrous opiate epidemic. The sad truth is that our governments and our society have not even come close to sufficiently implementing the Harm Reduction techniques necessary to reach the opiate-addicted community.
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